Effect of fatigue on reading computed tomography examination of the multiply injured patient

Comparing diagnostic findings and cost of whole body computed tomography to traditional diagnostic imaging in polytrauma patients

OBJECTIVE

To compare the diagnostic utility of traditional diagnostic tests (ie, radiographs and focused assessment using sonography for trauma [FAST] scans) to whole-body computed tomography (WBCT) for characterizing injuries in polytrauma patients. A secondary objective was to compare costs of traditional diagnostic tests to WBCT.

DESIGN

Prospective, observational study.

SETTING

Private, level 1 veterinary trauma center.

ANIMALS

Convenience sample of 21 client-owned cats and dogs presenting with polytrauma.

INTERVENTIONS

Abdominal and thoracic FAST were performed by the primary clinician, if indicated. Radiographs were performed on areas concerning for trauma at the primary clinician's discretion. A WBCT was performed on each patient within 24 h of presentation and was blindly interpreted by a board-certified radiologist. Patients were only placed under anesthesia if further procedures were planned. IV contrast administration was employed at the discretion of the primary clinician and radiologist.

MEASUREMENTS AND MAIN RESULTS

Twenty-one patients (14 dogs and 7 cats) were enrolled. Sources of trauma included blunt force (80%), penetrating wounds (10%), and unknown sources (10%). Twelve injuries were missed on traditional diagnostics tests. Injuries missed on traditional diagnostic workup included pneumothorax, pneumomediastinum, pulmonary contusions, pleural effusion, traumatic bulla, peritoneal effusion, and an appendicular skeleton fracture. A distal metacarpal fracture was missed on WBCT. Traditional diagnostic tests misdiagnosed a diaphragmatic hernia and a ruptured urinary bladder, whereas WBCT was able to rule out these injuries. There were no adverse outcomes associated with missed injuries. The median cost of traditional diagnostic tests was significantly less than the cost of WBCT (P < 0.001).

CONCLUSIONS

Although cost is higher, WBCT is a single test that can provide more comprehensive information and may help decrease the risk of missed injuries compared to traditional diagnostic tests. WBCT may be considered as a first-line diagnostic in severely traumatized patients.

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment

BACKGROUND

We examined the visibility of fractures of hand and forearm in whole-body CT and its influence on delayed diagnosis. This study is based on a prior study on delayed diagnosis of fractures of hand and forearm in patients with suspected polytrauma.

METHODS

Two blinded radiologists examined CT-scans of patients with fractures of hand or forearm that were diagnosed later than 24 h after admission and control cases with unremarkable imaging of those areas. They were provided with clinical information that was documented in the admission report and were asked to examine forearm and hands. After unblinding, the visibility of fractures was determined. We examined if time of admission or slice thickness was a factor for late or missed diagnoses.

RESULTS

We included 72 known fractures in 36 cases. Of those 65 were visible. Sixteen visible fractures were diagnosed late during hospital stay. Eight more fractures were detected on revision by the radiologists. Both radiologists missed known fractures and found new fractures that were not reported by the other. Missed and late diagnoses of fractures occurred more often around 5 pm and 1 am. Slice thickness was not significantly different between fractures and cases with fractures found within 24 h and those found later.

CONCLUSIONS

The number of late diagnosis or completely missed fractures of the hand and forearm may be reduced by a repeated survey of WBCT with focus on the extremities in patients with suspected polytrauma who are not conscious.

LEVEL OF EVIDENCE

III.

The Impact of Fatigue on Complex CT Case Interpretation by Radiology Residents

RATIONALE AND OBJECTIVES

To examine the effect of fatigue on diagnostic performance and interpretation of complex CT trauma studies by radiology residents.

MATERIALS AND METHODS

Ten 2nd, 3rd, and 4th year radiology residents were given 1 hour to review as many complex CT cases as they could, once when they were fresh and once when they were fatigued (after a full day or night of diagnostic reading activity). Number of cases completed, interpretation accuracy and time per case were analyzed.

RESULTS

On average readers completed 7.5 cases when fresh and 7.3 when fatigued, with 4th and 3rd year residents spending more time per case when fresh than fatigued and 2nd year residents spending more time when fatigued. The total number of true positives for major (fresh mean = 29.4 vs fatigued mean = 24.1) and minor (fresh mean = 23.30 vs fatigued mean = 18.90) findings decreased for fresh vs fatigued; and there was a significant difference as a function of year of residency (F = 4.72, p = 0.027). The 4th year residents had the most TPS in both conditions, followed by 3rd then 2nd year residents. There were more false positives when fatigued than fresh.

CONCLUSION

Fatigue significantly impacts radiologic diagnostic efficiency and efficacy, and differs as a function of year of residency.

Full Resolution Simulation for Evaluation of Critical Care Imaging Interpretation; Part 1: Fixed Effects Identify Influences of Exam, Specialty, Fatigue, and Training on Resident Performance

RATIONALE AND OBJECTIVES

To describe our full-resolution simulation of critical care imaging coupled with posthoc grading of resident's interpretations and present results from the fixed effects terms in a comprehensive mixed regression model of the resulting scores.

MATERIALS AND METHODS

The system delivered full resolution DICOM studies via clinical-grade viewing software integrated with a custom built web-based workflow and reporting system. The interpretations submitted by participating residents from 47 different programs were graded (scores of 0-10) on a case by case basis by a cadre of faculty members from our department. The data from 5 yearly (2014-2018) cycles consisting of 992 separate 65 case, 8 hour simulation sessions were collated from the transaction records. We used a mixed (hierarchical) statistical model with nine fixed and four random independent variables. In this paper, we present the results from the nine fixed effects.

RESULTS

There were 19,916/63,839 (27.0%, CI 26.7%-27.4%) scores in the 0-2 range (i.e., clinically significant miss). Neurological cases were more difficult with adjusted scores 2.3 (CI 1.9-3.2) lower than body/musculoskeletal cases. There was a small (0.3, CI 0.20-0.38 points) but highly significant (p<0.0001) decrease in score for the final 13/65 cases (fifth quintile) as evidence of fatigue during the last hour of an 8 hour shift. By comparing adjusted scores from mid-R1 (quarter 3) to late-R3 (quarter 12) we estimate the training effect as an increase of 2.2 (CI 1.90-2.50) points.

CONCLUSION

Full resolution simulation based evaluation of critical care radiology interpretation is being conducted remotely and efficiently at large scale. Analysis of the resulting scores yields multiple insights into the interpretative process.

Impact of blue light filtering glasses on computer vision syndrome in radiology residents: a pilot study

Computer vision syndrome (CVS) is an umbrella term for a pattern of symptoms associated with prolonged digital screen exposure, such as eyestrain, headaches, blurred vision, and dry eyes. Commercially available blue light filtering lenses (BLFL) are advertised as improving CVS. Our pilot study evaluates the effectiveness of BLFL on reducing CVS symptoms and fatigue in a cohort of radiologists. A prospective crossover study was conducted with ten radiology residents randomized into two cohorts: one wearing BLFL first then a sham pair (non-BLFL), and the other wearing a sham pair first then BLFL, over two weeks during normal clinical work. Participants filled out a questionnaire using the validated computer vision syndrome questionnaire (CVS-Q) and the Swedish Occupational Fatigue Inventory (SOFI). The majority of symptoms [11/16 (68.8%) and 13/16 (81.3%) symptoms on the CVS-Q and SOFI, respectively] were reduced (i.e., symptoms less severe) with the BLFL compared to the sham glasses. Females rated symptoms of sleepiness and physical discomfort in the SOFI, and overall CVS-Q, as more severe. Postgraduate year (PGY)-2 residents rated all symptoms as more severe than PGY-3/4s. BLFL may ameliorate CVS symptoms. Future studies with larger sample sizes and participants of different ages are required to verify the potential of BLFL.

Optimizing Ergonomics in Breast Imaging

Breast imaging radiologists spend many hours seated at workstations and are therefore at high risk for repetitive strain injuries and computer vision syndrome. In addition, many perform hand-held sonography and image-guided procedures, which may present additional ergonomic challenges. In this article, we describe optimal ergonomics for breast imaging radiologists and discuss additional strategies to mitigate risks from work-related injury and improve overall physical well-being.

Fatigue in radiology: a fertile area for future research

Fatigue in radiologists may be responsible for a large number of medical errors. This review describes the latest research on fatigue in radiology. This includes measurement methods, and recent evidence on how fatigue affects accuracy in laboratory test conditions and in clinical practice. The extensive opportunities for future research in the area are explored, including testing interventions to reduce fatigue-related error, and further understanding of which fatigue measures correlate with errors. Finally we explore the possibility of answering these questions using large population-based observational studies and pragmatic integrated randomised controlled trials.

Increasing display luminance as a means to enhance interpretation accuracy and efficiency when reducing full-field digital mammography dose

Reducing dose increases noise impacting image quality but can be offset by increasing display luminance. Two contrast detail mammography images were obtained at 26 kV and the same distance between detectors, at 45 and 50 mAs resulting in entrance surface doses of 7.09 and 7.88 mGy, respectively. They were processed to make average gray level of the background independent of the dose level while maintaining original SNR. Eight radiologists viewed the images at 420, 1000  cd/m2 , and SpotView™ a tool that resulted in an average display luminance of 3138.8  cd/m2 . Percent correct (PC) for all three luminances was higher for high versus low dose. Performance was always higher with high dose no matter what the luminance. For low dose, PC was highest with SpotView™, and SpotView™ and 1000  cd/m2 were significantly higher than 420  cd/m2 . At high dose, SpotView™ PC was significantly higher than both lower luminances. Average time per image was lower in high dose, and, at both doses, time decreased as luminance increased, with SpotView™ having significantly shorter times. Increasing luminance from 420 to 1000  cd/m2 significantly increases target detection by ∼3.0% and with SpotView™ by ∼6.2% . Increasing display luminance with SpotView™ significantly decreases reading time by 16.0%.